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A study led by researchers at the San Francisco VA Medical Center (SFVAMC) indicates that the U.S. Department of Veterans Affairs (VA) was able to significantly improve the quality of the health care services it provides through a major overhaul of its system that began in 1995.

The most sweeping changes included the implementation of measurements of quality- of- care indicators, accountability and incentives for improvement of those indicators over time and the implementation of electronic medical records.
“What we saw after the institution of these changes was that quality improved dramatically and quickly. By 1997, nearly all the quality markers had significantly improved compared to what they were in 1995, and they continued to improve every year through 2000,” said Ashish K. Jha, MD, lead author on the paper. Jha was a physician in general internal medicine at the SFVAMC and an assistant professor of medicine at University of California, San Francisco (UCSF) at the time he conducted this research.
The study, published in the May 29 issue of the New England Journal of Medicine, also compares the quality of care in the VA health system with Medicare fee-for-service care. “For all measures that the two systems had in common, the VA performed much better than Medicare,” said Jha, who is now a research fellow at Boston’s Brigham and Women’s Hospital and the Harvard School of Public Health.
In 2002, the Institute of Medicine recognized the VA for implementing the kind of changes it had recommended the previous year for improving the quality of health care in America. “I think there are key initiatives that the VA instituted that any health care system could adopt,” Jha said. He added that the reengineered VA health care system “really is an excellent model of how health care can and should be run in this country.”
To assess performance on an on-going basis, clinical managers were provided data from the VA’s External Peer Review Program. The program uses independent reviewers trained by the West Virginia Medical Institute. The data used in the current study represented all VA locations nationwide and included between 50,000 and 90,000 individual medical records.
Reviewers gathered data on standard quality of care indicators, including those for preventive care, such as the frequency of mammography, vaccination and colorectal-cancer screening. The data they gathered also included markers for quality outpatient care: reaching target blood pressure readings for hypertension patients, prescription of aspirin within 24 hours of a myocardial infarction and semiannual cholesterol screening for diabetes patients.
Jha and his colleagues found significant improvement for all nine quality-of-care indicators measured by the VA between 1994 and 2000. They also found that the VA outperformed Medicare on all 11 markers the two systems had in common between 1997 and 1999, and on 12 of 13 indicators measured between 2000 and 2001.
“These findings suggest how much improvement is possible when those responsible for the management of health care organizations have clear incentives to maximize quality and good information about their progress in achieving that goal,” said senior author, R. Adams Dudley, MD, MBA, UCSF assistant professor of medicine and health policy.
According to Jha, the implementation of a nationwide electronic medical records system was also a key factor, allowing the VA to streamline care. For example, when a physician wants to know if a patient has received a pneumonia vaccine, he or she can look up the information instantly. In contrast, looking through a detailed paper chart might take 20 minutes and will not tell the physician whether or not the patient had the vaccine given at another VA location. “The system streamlines the process and makes providing high-quality care easier,” Jha said.
Additional authors included Jonathan B. Perlin, MD, PhD, deputy under secretary for health, Veterans Health Administration, Washington, DC; and Kenneth W. Kizer, MD, MPH, president and CEO, National Quality Forum, Washington, DC.
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